SAN JUAN, Puerto Rico - Going to the doctor in Puerto Rico has for years often meant getting in line. Now, it might mean getting on a plane.
A medical exodus is taking place in the Caribbean territory as doctors and nurses flee for the U.S. mainland, seeking higher salaries and better reimbursement from insurers. Many of their patients, frustrated by long waits and a scarcity of specialists, are finding they have no choice but to follow them off the island.
Among them is Marilu Flores, a 60-year-old rural mail carrier who is battling advanced rheumatoid arthritis.
She not only is flying to the U.S. mainland to receive treatment; she's moving to Texas.
"The best doctors left a long time ago," she said.
In the last five years, the number of doctors in Puerto Rico has dropped by 13 per cent, from 11,397 to 9,950, according to the island's Medical Licensing and Studies Board. The biggest losses are primary care physicians and specialists within a specialty, such as thoracic oncologists.
Of the roughly 400 cardiologists who practiced in Puerto Rico about five years ago, only about 150 remain. The number of anesthesiologists has dropped from roughly 300 to about 100 in roughly the same time period, said Dr. Eduardo Ibarra, president of the island's Association of Surgeons.
"Same with the neurosurgeons. They don't even number 20 now," Ibarra said. "There are no specialized surgeons in certain areas."
Those seeking a thoracic oncologist, for example, have to go to Florida, if they can afford it.
"It's truly catastrophic," he said.
The exodus of doctors is part of a larger wave of professionals who have left the U.S. island territory in recent years, settling in states such as Florida and New York, where there is a big demand for bilingual workers, especially police and nurses. Many Puerto Ricans also seek to escape a wave of violent crime and higher cost of living. Almost a million more Puerto Ricans now live on the mainland than on the island.
Medical professionals say they expect the situation will worsen.
President Barack Obama's new health care law means U.S. states will soon seek more doctors amid an influx of patients, said Dr. Guillermo Tirado, an internal medicine specialist in Puerto Rico.
"All states are preparing to cull a lot of doctors from Puerto Rico," he said. "If we have a big exodus now, we're going to see it get worse ... There hasn't been a revolution yet because the escape valve is to buy a plane ticket to Orlando," referring to the many patients who fly to the U.S. for treatment if they can afford it.
Puerto Rico currently does not meet federal recommendations on the number and types of doctors needed per capita, Tirado said.
The island of 3.7 million people has no more than two pediatric neurosurgeons, even though guidelines state there should be at least one pediatric neurosurgeon per roughly 80,000 people, he said.
Puerto Rico also lacks 93 full-time primary care physicians to adequately cover the medical needs of the population, according to statistics from the U.S. Health Resources and Services Administration, which tracks areas suffering from a shortage of health professionals. Of the island's 78 municipalities, 37 need more health care professionals, including the capital of San Juan and Ponce, the island's second largest city. The island has roughly 7,000 primary care physicians, Ibarra said.
At the same time, the island's medical tourism industry is growing, with two new hospitals being built in Manati and Bayamon, catering mostly to foreigners from elsewhere in the Caribbean, and even some from the U.S. mainland, said Pedro Pierluisi, the island's representative in Congress who has limited voting powers. "In a way, it's inconsistent," he said.
Tirado said U.S. patients seek mostly cosmetic procedures, while Caribbean patients often seek specialists not available on their islands, such as endocrinologists.
"It's a paradox," he said, noting that U.S. tourists who need other medical services while on vacation often choose to go back to the mainland in an air ambulance.
To prevent doctors from leaving, one legislator has introduced a bill that would require medical students to stay and practice in Puerto Rico the amount of time it took to complete their residency if the government paid for it.
"We're being left without specialists," said Jose Aponte, former president of the House of Representatives.
The government pays for the residencies of at least 95 per cent of all Puerto Rican medical students, investing $35,000-$45,000 a year for each, Aponte said. Puerto Rico has four medical schools, and roughly 400 medical students graduate a year.
If the bill is approved, students would have to reimburse the government the cost of their residency if they leave before practicing medicine for the required time.
"Currently, they are disappearing from the scene because they go to the U.S., where they have received incredible offers," he said.
Tirado agreed: "Job offers rain down every day," he said. "It's a huge bombardment."
Family and general practitioners in Puerto Rico earn about $72,000 a year, while in the U.S. they earn about $180,000, according to 2012 statistics from the U.S. Bureau of Labor.
That's partly due to the lower standard of wages on the island, where the median wage is less than $28,000 a year, far below mainland income. Ibarra and Tirado say peculiarities in the island's health insurance system also force doctors to accept less income — or to leave.
Puerto Rican health care providers also get less reimbursement from Medicare for particular services than do those in any other U.S. state or territory, Pierluisi said. They get about 20 per cent less than those on the U.S. Virgin Islands and the base rate for hospital patients is 14 per cent less than on the U.S. mainland, he said.
Currently, more than 670,000 people in Puerto Rico use Medicare.
"It's a huge number of patients for doctors," said Pierluisi. "It's the best plan we have. It serves as the top plan. If Medicare is not paying our physicians well, the commercial insurers in the private sector will do the same."
While the U.S. government is scheduled to revise how Medicare reimbursements are determined next year, that won't stop doctors from leaving, Tirado said.
A recent study commissioned by the island's Association of Surgeons found the problem is aggravated by retiring doctors, and by the fact that fewer doctors are studying allergy, endocrinology, geriatrics and urology. The study also warned about a scarcity of specialists including cardiologists, anesthesiologists and orthopedic surgeons.
Flores said she is looking forward to not having to worry about scarcity of doctors once she moves to the U.S.
"I've already taken the decision to quit my job," she said. "It pays well, but my health is more important."